Effects of learning content in context on knowledge acquisition and recall: a pretest-posttest control group design

Learning in context: Undergraduate students' knowledge and the content retention of anatomy between discipline-specific and integrated course approaches

Undergraduate introductory human anatomy and human physiology courses are either taught as discipline-specific or integrated anatomy and physiology (A&P) sequences. An institution underwent a curricular revision to change the course approach from discipline-specific Human Anatomy and Human Physiology to an integrated A&P I and II sequence, allowing the unique opportunity to explore the potential role of contextual learning in academic achievement and content retention. Mediation and moderation analysis was used to evaluate lecture examinations, laboratory practical examinations, and anatomical content retention between the different course approaches. Undergraduate students in the integrated A&P I course approach performed significantly better on lecture assessments and had a higher anatomy content retention rate at the end of the year than students enrolled in the standalone Human Anatomy course. The lecture examination averages between Human Physiology and A&P II (the second course in the sequence), as well as the anatomy laboratory practical examinations, were not significantly different between discipline-specific and integrated course approaches. The results suggest contextual learning-providing physiological context to anatomical structures-increases the anatomical content retention and academic achievement overall.

Evaluating an obstetrics and gynecology teaching program for medical students incorporating simulation-based education underpinned by cognitive load theory

Although there have been previous publications on curriculum innovations in teaching O&G to medical students, especially utilizing simulation-based education, there have been none, as far as we know, incorporating and evaluating the outcomes using cognitive load theory. The aim of this article was to describe the introduction, implementation, and evaluation of an innovative teaching program in O&G, incorporating simulation-based education, underpinned by cognitive load theory. Cognitive load is defined as the amount of information a working memory can hold at any one time and incorporates three types of cognitive load-intrinsic, extraneous, and germane. To optimize learning, educators are encouraged to manage intrinsic cognitive load, minimize extraneous cognitive load, and promote germane cognitive load. In these sessions, students were encouraged to prepare in advance of each session with recommended reading materials; to limit intrinsic cognitive load and promote germane cognitive load, faculty were advised ahead of each session to manage intrinsic cognitive load, an open-book MCQ practice session aimed to reduce anxiety, promote psychological safety, and minimize extraneous cognitive load. For the simulation sessions, the faculty initially demonstrated the role-play situation or clinical skill first, to manage intrinsic cognitive load and reduce extraneous cognitive load. The results of the evaluation showed that the students perceived that they invested relatively low mental effort in understanding the topics, theories, concepts, and definitions discussed during the sessions. There was a low extraneous cognitive load. Measures of germane cognitive load or self-perceived learning were high. The primary message is that we believe this teaching program is a model that other medical schools globally might want to consider adopting, to evaluate and justify innovations in the teaching of O&G to medical students. The secondary message is that evaluation of innovations to teaching and facilitation of learning using cognitive load theory is one way to contribute to the high-quality training of competent future healthcare workers required to provide the highest standard of care to women who are crucial to the overall health and wellbeing of a nation.

Relationship Between Cognitive Load Theory, Intrinsic Motivation and Emotions in Healthcare Professions Education: A Perspective on the Missing Link

Cognitive Load Theory (CLT) is one of the key cognitive theories that have been used to assess learners' information and working memory load. CLT has been applied to Simulation Based Education (SBE) and optimizing instructional design. However, a challenge that occurs is that these high-fidelity simulations and mannequins of critically ill patients can elicit negative emotions in learners which can unfavorably impact the learning process. There is also a potential for cognitive overload if the simulation is more authentic and requires more dynamic interactions and lead to high levels of anxiety due to a novel learning environment, which can also have detrimental effects on learning process. Hence, it is critical for health professional educators (HPE) to know how to minimize cognitive load to improve learning as a professional in a workplace setting. The literature on the role of emotions, intrinsic motivation, cognitive load is scarce in HPE literature. Specifically when not being studied together at once since they move dynamically together and affect the learning for the learner. Therefore, the purpose of this perspective paper is to cover the gap in the literature and propose a framework and recommendation for future HPE research.

Measurement and Management of Cognitive Load in Surgical Education: A Narrative Review

BACKGROUND

Cognitive load should be considered in designing optimal educational programs in health care. Despite the highly demanding nature of surgery and surgical education, a consensus on how to manage cognitive load has not been established. The objective of this review is to map out how recent surgical education research incorporates cognitive load.

METHODS

A literature search was performed using keywords related to cognitive load and digital education up to December 2021. Studies published in English relevant to assessment and management of cognitive load in surgical education were included. Terminology, assessment tools, association with different surgical procedures and training modalities, and programs considering cognitive load were reported.

RESULTS

We identified several terms to describe cognitive load. Cognitive load was measured by subjective, self-reported questionnaires and by objective measurements, such as physiological parameters or estimated by reaction time to secondary tasks. Subjective measurements reported cognitive load in one or multiple dimensions. Correlations between subjective and objective measurements were shown in multiple studies. Overall, higher cognitive load was observed in training for more complex tasks and high-fidelity modalities, and among less experienced trainees. Cognitive load theory has been lately incorporated into designing teaching programs.

CONCLUSIONS

A broad range of terms and assessment tools were identified for cognitive load. To maximize the learning outcome, management of cognitive load is necessary in surgical education. This review summarizes the current knowledge in assessment and management of cognitive load in surgical education and provides suggestions for future studies.

Anxiety is associated with extraneous cognitive load during teaching using high-fidelity clinical simulation

High-fidelity clinical simulation is currently a well-established teaching tool. However, high-fidelity representations of patients in critical conditions have the potential to elicit emotions among learners and impact their cognitive load (CL). Teaching with clinical simulation may induce both emotional and cognitive overloads. The relationship between anxiety and CL during clinical simulation was studied. Forty-one undergraduate medical students participated in this study; 19 males and 22 females. The state-anxiety component of State-Trait Anxiety Inventory was administered during clinical simulation teaching sessions at time points: pre-scenario, post-scenario and post-debriefing. The Cognitive Load Scale (Leppink et al.) questionnaire was also completed post-scenario. This assessed the three components of CL: intrinsic cognitive load (ICL), extraneous cognitive load (ECL) and self-perceived learning (SPL). Median CL scores for ICL, ECL and SPL were compared between groups of low-anxiety and high-anxiety participants using a Mann-Whitney U test. State-anxiety scores were high for both the pre-scenario and post-scenario time points with a significant reduction following post-debriefing. The median (interquartile range) state-anxiety scores were 41.0 (33.0-50.0), 46.0 (33.0-52.0) and 31.0 (23.0-39.0) for the pre-scenario, post-scenario and post-debriefing time points respectively. Students with high state-anxiety had higher ECL scores (median = 2.0) than students with low state-anxiety (median = 0.9) at the post scenario time point (U = 220, p = 0.043). No statistical relation was seen with state-anxiety for either ICL or SPL. State-anxiety immediately after the simulation scenario is associated with ECL but not ICL or SPL.

COVID-19 Disruptions in Health Professional Education: Use of Cognitive Load Theory on Students' Comprehension, Cognitive Load, Engagement, and Motivation

This study explored the impact of online lectures that were developed using principles of cognitive load theory (CLT) and cognitive theory of multimedia learning (CTML) on health profession students' lecture comprehension, cognitive load, cognitive engagement, and intrinsic motivation in learning. A total of 215 first-year undergraduate students in medical, dentistry, and nutrition programs participated in this pre-post quasi experimental study. The students attended a typical face-to-face lecture on Day-1 of the intervention, followed by a CLT-based online lecture 8 weeks thereafter. Their comprehension of the lecture topics was measured through pre- and post-lecture assessments, and their cognitive load, cognitive engagement, and motivation were measured immediately after each lecture session. The analysis revealed that the CLT-based online lectures promoted the students' comprehension of the lecture content (p < 0.001), self-perceived learning (p < 0.001), engagement toward the learning material, and motivation to learn (p = 0.025). It was also effective at reducing the students' intrinsic and extraneous cognitive loads (p < 0.001). Hence, designing online lectures using CLT and CTML principles could be an effective method to promote students' knowledge and comprehension, cognitive engagement, and learning motivation. However, further research is needed to investigate the applicability and impact of CLT-based online lectures in non-health profession disciplines.

Efecto de la respiración consciente en la tarea de atención en adultos

El presente ensayo pretende revisar las publicaciones asociadas a la tarea de atención en adultos en virtud del impacto de la respiración consiente. Las técnicas de respiración en los diferentes estilos de meditación han cobrado relevancia a la hora de evaluar el proceso de enseñanza aprendizaje en niños, principalmente en algunas funciones superiores cognitivas como lo es el control inhibitorio. En adultos, hay información difusa no sistematizada de cómo podrían impactar estas prácticas en el proceso de enseñanza aprendizaje, considerando que los adultos presentan supresión de la neurogénesis y la neuroprotección, lo que conduce a alteraciones patológicas en el estado de ánimo, la atención, memoria y aprendizaje, según lo descrito por Innes y Selfe (2014). La evidencia determina que es factible generar una intervención para la mejora del ambiente de aprendizaje, basado en el impacto que produce en los procesos atencionales. Este impacto podría determinar la adecuación de políticas públicas o intervenciones de instituciones públicas o privadas, con el fin de potenciar el aprendizaje en adultos y limitar el deterioro cognitivo de estos, a través del estímulo de sus funciones cognitivas que produce la respiración consiente.

The Hidden Curriculum of Utilisation of Imaging and Unregulated Digital Resources within Clinical Education

Clinical education has changed dramatically over the last 30 years. The increasing use of imaging and visualisation technologies within medical, dental and other healthcare sciences education curricula is taken for granted, with little consideration given to the agenda behind the colonisation of the basic sciences curricula with these technologies or their ultimate utility with regards to patient care. Sufficient critique is rarely given prior to the incorporation of imaging modalities into teaching and learning, and the hidden curriculum remains deeply buried under the impetus to 'move with the times'. Coupled with increasingly easily accessible but unregulated streamed digital teaching resources widely utilised in healthcare professions' curricula, there remains a danger that future generations of clinicians may be exposed to erroneous information that could ultimately impact on the safety of their patients. Educators must develop a reflective approach, and together with institutions develop a collective responsibility to integrate and map evidence-based and clinically-relevant approaches within the respective curricula, rather than bombard undergraduates with the latest technology and never-ending (and sometimes unreliable and unregulated) information without awareness of the potential dangers lurking within their preferred teaching methods and ideologies. Healthcare professionals must subject teaching resources utilised within their curricula to the same scrutiny that textbooks undergo, with content accuracy and endorsement via reputable sources, preferably peer reviewed and traceable, taking precedence.

Second-Year Nursing Students' Retention of Gross Anatomical Knowledge

Human anatomy is a foundational course in nursing education, however, there is growing concern that students do not retain enough anatomical knowledge to successfully apply it in clinical settings. The aim of this study was to determine retention level of anatomy knowledge among second-year nursing students from their first-year anatomy class, and to determine if there is a difference in level of retention based on organ system. For each system, second-year students were asked to answer 9 to 11 multiple-choice questions (MCQs), and the scores from these quizzes were compared to matched test items from their first-year anatomy examinations. There was a significant decrease in the overall mean score from 83.05 ± 8.34 (±SD) in first year to 54.36 ±12.9 in second year (P = 0.0001). Retention levels were system specific. System-specific knowledge retention was highest for the gastrointestinal system (89.7%), respiratory system (88.5%), and genitourinary system (83.6%). This was followed by the integumentary system (80.1%), special senses (79.4%), nervous system (74.9%), and musculoskeletal system (69.3%). Retention was lowest for the lymphatic system (64.3%), cranial nerves (58.8%), vascular system (53.9%), and head and neck (42.6%). The present study shows that nursing students' anatomy knowledge retention was comparatively higher than rates reported by others in medical and allied-health students. The researchers are now investigating knowledge retention in third- and fourth-year nursing students. Further investigation into why retention is higher for specific systems and intervention strategies to improve knowledge acquisition and retention in nursing students is recommended.

Musculoskeletal Anatomy Knowledge Retention in the Macquarie University Chiropractic Program: A Cross-Sectional Study

Attrition of anatomy knowledge has been an area of concern in health professions curricula. To ensure safe and effective clinical practice, the study of chiropractic requires a good knowledge of musculoskeletal anatomy. In this study, musculoskeletal limb knowledge retention was investigated among students in the 5-year chiropractic program at Macquarie University, Australia. A test of 20 multiple-choice questions, categorized into low-order (LO) and high-order (HO) cognitive ability according to Bloom's Taxonomy, was developed. Students enrolled in the program were invited to participate with 257 of the 387 choosing to participate, (response rate ranging 56%-72% per year level). No attrition of knowledge across the years was observed, instead, a significant increase in knowledge, measured by total LO and HO scores (P < 0.0005), throughout the program. There were significant increases in both low and high cognitive scores which were not uniform, with high-order scores increasing significantly in the last two year levels. The increase of knowledge, may be explained, at least partially, by the vertical and horizontal integrated curriculum. Retrieval of knowledge, especially in clinically applied formats, may have led to an enhanced ability to apply anatomy knowledge and account for the increased scores in the high-order knowledge seen in the later clinical years. Evaluating anatomy knowledge retention at different cognitive levels seems to provide a better assessment and is worth considering in future anatomy educational research.

Treating the Orthopaedic Trauma Knowledge Gap: Quantification of Orthopaedic Resident Knowledge Gaps and Validation of a Multimodal Course to Address the Deficiencies

OBJECTIVES

To determine whether knowledge-based deficiencies are adequately addressed at the AO North America Basic Principles of Fracture Management course.

DESIGN

Pretest, posttest.

SETTING

Eighteen national trauma courses.

PARTICIPANTS

Two thousand one hundred forty-nine learners.

INTERVENTION

Pre- and postcourse 20-item tests of basic fracture knowledge, including 14 trauma topics.

MAIN OUTCOME MEASURES

Deficiencies were defined as <60% correct answers on the precourse test. Postcourse knowledge gaps were defined as <75% correct responses.

RESULTS

Deficiencies were noted in 7 of the 14 topics on the precourse test. All topics with deficiencies on the precourse test were shown to have statistically significant improvement in postcourse test scores. All topics without deficiencies were shown to have statistically significant improvement in postcourse test scores. The average overall precourse test score was 63% (95% confidence interval, 61%-65%), and the average overall postcourse test score was 81% (95% confidence interval, 79%-83%). The pretest to posttest difference was statistically significant (P < 0.05). The control questions, covering material that was not discussed in the course, did not have statistically significant improvement in scores.

CONCLUSIONS

Residents are entering residency programs with limited knowledge of fracture care, and significant gaps remain at the junior level at the time of course participation, suggesting that supplemental fracture courses play an important role in resident education. Validation of short-term learning is possible through a pretest and posttest technique, and it can guide design changes, as opposed to relying on satisfaction surveys alone.

Anatomy integration: Effective change or change of affect?

Anatomy is fundamental to clinical practice, is considered a rite of passage in becoming a physician and is key to professional identity formation. The anatomy course that began the medical curriculum at the University of New Mexico School of Medicine was recently dissolved to address content and process gaps in the pre-clinical curriculum. Anatomy was integrated into the organ system blocks to make room for new courses to address content gaps. Previous reports of anatomy integration document more positive attitudes and perceptions to teaching anatomy in context, as compared to an independent course. The current prospective study compared two medical student cohorts to determine the effects of teaching anatomy in and out of context on the cognitive and affective domains of learning. In a pre, post, and follow-up design, methods included content assessments, confidence probes, and attitude surveys informed by focus groups. Results indicated that anatomical knowledge and student confidence was gained and mastered in both curricula. Initial acquisition of content was higher in the integrated curriculum, but not maintained. Students in the integrated curriculum displayed a different relationship to learning anatomy, appearing more concerned with their personal progression than with the connection of anatomy to medical practice or patient care. These students also agreed less with statements related to working in teams, reflective practices and professional identity formation. Further studies will determine if this difference will diminish with continued exposure to anatomy and may inform future curricular adjustments. Anat Sci Educ. © 2018 American Association of Anatomists.

Cognitive load theory: Practical implications and an important challenge

The field of medical education has adopted a wide variety of theories from other fields. A fairly recent example is cognitive load theory, which originated in educational psychology. Several empirical studies inspired by cognitive load theory and reviews of practical implications of cognitive load theory have contributed to guidelines for the design of medical education. Simultaneously, several research groups have developed instruments for the measurement of cognitive load in a medical education context. These developments notwithstanding, obtaining evidence for different types of cognitive load remains an important challenge. Therefore, the aim of this article is twofold: to provide medical educators with three key guidelines for the design of instruction and assessment and to discuss several fundamental issues in the remaining challenges presented by different types of cognitive load. The guidelines revolve around minimizing cognitive activity that does not contribute to learning, working with specific learning goals in mind, and appreciating the multifaceted relation between learning and assessment. Key issues around the types of cognitive load include the context in which learning occurs, the continued use of single-item mental effort ratings, and the timing of cognitive load and learning outcome measurements.

Cadaveric dissection as an educational tool for anatomical sciences in the 21st century

Anatomical education has been undergoing reforms in line with the demands of medical profession. The aim of the present study is to assess the impact of a traditional method like cadaveric dissection in teaching/learning anatomy at present times when medical schools are inclining towards student-centered, integrated, clinical application models. The article undertakes a review of literature and analyzes the observations made therein reflecting on the relevance of cadaveric dissection in anatomical education of 21st century. Despite the advent of modern technology and evolved teaching methods, dissection continues to remain a cornerstone of anatomy curriculum. Medical professionals of all levels believe that dissection enables learning anatomy with relevant clinical correlates. Moreover dissection helps to build discipline independent skills which are essential requirements of modern health care setup. It has been supplemented by other teaching/learning methods due to limited availability of cadavers in some countries. However, in the developing world due to good access to cadavers, dissection based teaching is central to anatomy education till date. Its utility is also reflected in the perception of students who are of the opinion that dissection provides them with a foundation critical to development of clinical skills. Researchers have even suggested that time has come to reinstate dissection as the core method of teaching gross anatomy to ensure safe medical practice. Nevertheless, as dissection alone cannot provide uniform learning experience hence needs to be complemented with other innovative learning methods in the future education model of anatomy. Anat Sci Educ 10: 286-299. © 2016 American Association of Anatomists.

Trust your struggle

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Measuring cognitive load: mixed results from a handover simulation for medical students

INTRODUCTION

The application of cognitive load theory to workplace-based activities such as patient handovers is hindered by the absence of a measure of the different load types. This exploratory study tests a method for measuring cognitive load during handovers.

METHODS

The authors developed the Cognitive Load Inventory for Handoffs (CLI4H) with items for intrinsic, extraneous, and germane load. Medical students completed the measure after participating in a simulated handover. Exploratory factor and correlation analyses were performed to collect evidence for validity.

RESULTS

Results yielded a two-factor solution for intrinsic and germane load that explained 50 % of the variance. The extraneous load items performed poorly and were removed from the model. The score for intrinsic load correlated with the Paas Cognitive Load scale (r = 0.31, p = 0.004) and was lower for students with more prior handover training (p = 0.036). Intrinsic load did not, however, correlate with performance. Germane load did not correlate with the Paas Cognitive Load scale but did correlate as expected with performance (r = 0.30, p = 0.005) and was lower for those students with more prior handover training (p = 0.03).

CONCLUSIONS

The CLI4H yielded mixed results with some evidence for validity of the score from the intrinsic load items. The extraneous load items performed poorly and the use of only a single item for germane load limits conclusions. The instrument requires further development and testing. Study results and limitations provide guidance to future efforts to measure cognitive load during workplace-based activities, such as handovers.

Discussing dissection in anatomy education

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